1. To find documents related to your coverage, start by selecting
your state and your Medicare plan.
2. Select the state you reside in.
4. Download Plan Documents
H5454-002 Plan Documents
Covered Drug List
Pharmacy Directory
Pharmacy Directory (Spanish)
Evidence of Coverage – H5454-002
Evidence of Coverage – H5454-002 – (Spanish)
Summary of Benefits
LIS Premium Chart
Over-The-Counter Catalog
Star Rating – H5454
Star Rating – H5454 – (Spanish)
Annual Notice of Change – H5454-002
H5454-006 Plan Documents
Covered Drug List
Pharmacy Directory
Pharmacy Directory (Spanish)
Evidence of Coverage – H5454-006
Evidence of Coverage – H5454-006 – (Spanish)
Summary of Benefits
LIS Premium Chart
Over-The-Counter Catalog
Star Rating – H5454
Star Rating – H5454 – (Spanish)
Annual Notice of Change – H5454-006
General Documents
- MAPD Attestation
- Provider Attestation for SSBCI Benefits
- Provider Dispute Claim Reconsideration Request Form
- MAPD Scope of Appointment
- MAPD Enrollment Form
- Over-the-Counter (OTC) Product Catalog
- Admissions Form
- Appointment of Representative Form
- BAE Policy
- Coverage Determination Request Form
- Disenrollment Form
- Grievance Form
- Mail Order Drug Form
- Medical Reimbursement Claim Form
- Medication Therapy Management (MTM) Overview
- Medication Therapy Management (MTM) - Personal Rx List